Implant placement in atrophic ridge

173 Rating(s).


Posted on By snjezana pohl In Bone Grafting

Very thin ridge was cut utilizing piezo and expanded with Densah burs. Veneer augmentation was done utilizing 2/3 autogenous bone, 1/3 collagenized xenograft, lamina as scaffold. Lingual flap was released utilizing "Digitoclastic Technique". Healing abutments are placed to additionally fixate lamina and to increase soft tissue volume (Guided Gingiva Regeneration as described by dr. Salama). Re-entery is done yesterday by my student Ivana Balic, XP member. She repositioned the flap apically and sutured FGG to enhance KG.




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17 Comments

Re entery r 9 months after the first procedure.


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Snjezana, great series of surgical concepts and well performed. I often wonder whether to perform tissue grafting PRIOR to Bone regeneration? What are your thoughts here? Thanks again Maurice


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And once again the right question! This is what I asked Juan recently and what is the part of my lecture. In generally I advocate soft tissue thickening prior to hard tissue augmentation. And when I look back at this case, I would have done it before. Lamina is very friendly to overlaying soft tissue and healing abutments underneath the flap helped the soft tissue to develope. There was very little KG, but good vertical gingiva hight (healing abutments at uncovering have 5 mm hight).
Thank you for asking right questions each time!
See you soon
Snjezana


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Very nice work. great results! Thanks for sharing, ČESTITKE!


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Thank you, Damir, puno hvala:))
Best regards
Snjezana


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Great case Snjezana. I have a similar case done a few years ago with Osseodensification & Allograft/Autogenous combo. Will try and post later today. Maurice, I understand your thoughts regarding enhancing soft tissues prior to bone augmentation. There's an algorithm I follow, and I'd appreciate both your thoughts on it.


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Hi, Narayan,

it looks more and more that both of us have a lot of in common:))
Great input. It is good to have an algorithm, standardized procedures.
Your classification in > or < 2mm KG buccal makes sense. May be it is due to a long, long day in a clinic, but I don`t understand parts that I marked (attached). Would you be so kind and explain, please.
More and more I thicken the soft tissue in mandibula prior to hard tissue augmentation and simultaneously to implant placement, if insufficient. There is often crestal bone resorption already during osseointegration if gingiva is thin (especially if there is not a fixed provisional bridge to protect the area). The recent Linkevitius study says that 3mm vertical thickness is required. If we do vestibuloplasty and some FGG or CTG grafts during implant uncovering, we hardly improve vertical soft tissue thickness.
Can`t await to understand your algorithm completely!
thank you
Snjezana


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Hahaha, Snjezana- its not you, its me ! :-). I just did this before heading out for my Sunday breakfast ride. Thanks for pushing me. Hope this makes better sense


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Very good, Narayan.
The question is: should we include the vertical gingiva dimension (thickness) in this algorithm?
Cheers
Snjezana


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Agreed. We should.


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Great case Snjezana,

I think it makes more sense to augment soft tissue at uncovery stage as you reduce one surgery and you can perform vestibuloplasty at the same time.

How long did you wait before 2nd stage?
How good is the quality of bone compared to autogenous plate?
Often I find patients with insufficient ramus bone for harvest, this can be good alternative to non resorbable membranes.

Regards!


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Thank you, Andoni!
Regarding bone quality: it is not real bone bone like with Khoury technique but almost. In my first cases I didn`t wait enough and bone was softer and one could hardly say if lamina belongs to soft or hard tissue part. Since I wait longer (as recommended for each lamina type), it looks really good.
In this case a thick lamina was used and it took 8 months.
Regarding the best time for soft tissue enhancement - please see my answer to Narayan.
Soft tissue thickening prior to hard tissue augmentation is one surgery more. But if done in tunnel with allo- or xenograft (as described by HR Kazemi) it hardly causes inconvenience.
Thank you again. See you in New York? Great opportunity to discuss this topic:))
Best regards
Snjezana


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Great case Snjezana! Additional CTG at second stage makes sense for me. Especially considering much of the initial graft material converts to fibrous tissue during stage one.warmest wishes GF.


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Agree!
Thank you for your comment, Chuckopedia.
Snjezana


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Snjezana, great quality treatment. Thanks for sharing. I´ve never used the Lamina. I like the idea of Soft Tissue guided regeneration in this case.
A FGG is well recomended in this case.
My last question: why don´t add a 3rd implant? Just in case...? Regards
Jorge


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If you watch carefully the images, you can see that I tried to prepare an additional implant site, but it didn`t work, the cortical bone fractured. And at implant uncovering procedure the tissue around both implants looked good.
Now I am waiting for Rich and his question about provisional:))
Cheers
Snjezana


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😂😂😂


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